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Quality Assurance

It is the responsibility of the TB program to ensure that every
suspected or confirmed TB case that is reported receives

A complete diagnostic evaluation

An adequate regimen of TB medications

Appropriate measures to promote adherence
and completion of therapy

Public health workers assigned to hospitals and institutions
can play a key role in carrying out these responsibilities; however,
practices will vary from facility to facility and often the infection
control practitioner, hospital epidemiologist, or employee health
department will be primarily responsible for quality assurance.
Public health workers should collaborate with a facility's staff
to monitor the patient's care throughout the hospital or institutional
stay. This means assessing the patient's care periodically, after
a case has been reported and the initial patient interview has taken
place, and reporting any problems to the TB program.

This evaluation provides valuable information not only for the
medical diagnosis of TB, but also for assessing the patient's degree
of infectiousness and the possibility of disease caused by drug-resistant
organisms. If the medical history reveals a history of TB disease,
the public health worker should gather additional information from
the TB program and from the former provider, if possible; this information
should be supplied to the patient's current provider.

Persons suspected of having pulmonary or laryngeal TB should
have at least three sputum specimens examined by smear and culture.
In addition, follow-up bacteriologic examinations are important
for assessing the patient's infectiousness and response to therapy.
Public health workers should therefore monitor patients' laboratory
results throughout their stay in the facility to ensure that cases
are appropriately managed. To detect any drug resistance as soon
as possible, the initial M. tuberculosis isolate should
always be tested for its drug susceptibility pattern.

Adequate Regimen. Regimens for the treatment
of TB must contain multiple drugs to which the organisms are susceptible.
Therefore, the public health worker should help ensure appropriate
care by reporting the following problems to a supervisor:

The use of a non-standard regimen to treat TB disease

The use of a three-drug regimen instead of four drugs, in
an area with high levels of drug resistance (a prevalence of
INH-resistant TB of 4% or greater) or in treating a patient
at high risk for drug resistance

The addition of a single drug to a failing regimen

These problems can all lead to treatment failure and the emergence
of drug-resistant tubercle bacilli. The public health worker needs
to be familiar with the standard TB treatment regimens and with
local levels of drug resistance (see
Module 5, Treatment of
Tuberculosis Infection and Disease, and the latest American Thoracic
Society/CDC treatment recommendations for standard regimens).

Measures to Promote Adherence. As mentioned previously,
the public health worker will begin an assessment of the patient's
potential adherence during the initial interview. Throughout the
stay in the facility, the patient's adherence with the treatment
regimen should be monitored and the patient should be educated about
TB disease. If problems arise while the patient is in the facility
that create barriers to the patient's adherence (for example, moves
within the facility, staffing problems), the public health worker
should ensure that adherence barriers are promptly addressed and
resolved.

In addition to the duties mentioned above, public health workers
assigned to hospitals and institutions may become involved in

Infection-control activities within the facility, including
ongoing tuberculin skin-testing programs

Contact investigations within the facility

The administration and monitoring of treatment for LTBI
for patients or employees

Data collection for epidemiological research

It is important to keep in mind that the public health worker's
first priority should be the prompt identification and appropriate
management of active TB cases.

Discharge Planning

Discharge planning is the preparation of a detailed plan for
comprehensive care of a hospitalized or institutionalized patient
after that patient's discharge. For patients who leave a hospital
or institution, discharge planning is necessary to ensure
continuity of treatment and quality care. Discharge planning for
TB patients should begin soon after a suspected or confirmed TB
case is reported. It is usually a team effort, led by a nurse or
a facility's discharge planner. In some cases, a case manager assigned
by the public health department may be in charge of planning for
a patient's discharge. Team members often include at least two or
more of the following:

The discharge planner or case manager

Nurses or therapists involved in the patient's care

A social worker

The patient's physician

Expert consultants, if required

DOT outreach worker

An institution-based public health worker can also provide input
and share responsibility for ensuring that the TB patient is appropriately
managed after discharge.

The discharge planning team should meet while the patient is
in the facility to review the patient's treatment plan and develop
an adherence plan. An adherence plan is a written plan that
is based on the patient's understanding and acceptance of the TB
diagnosis, that addresses barriers to adherence, and that details
the method chosen to deliver treatment and monitor adherence for
that specific patient. If possible, the patient should be included
in this meeting to aid in decision-making. The treatment plan includes
the details of the medical regimen as ordered by the physician,
as well as plans for monitoring for adverse reactions and other
follow-up care.

The adherence plan should be developed with input from the patient
and from other key staff and health care providers. Adherence often
improves if the patient, the family (if possible), and the public
health worker develop an agreement that spells out the adherence
plan and states the responsibilities of the patient and of his or
her providers (see Module 9, Patient Adherence to Tuberculosis Treatment,
for further information).

The discharge team may identify problems other than TB that patients
are encountering. These problems may include other medical conditions,
inadequate housing, poverty, family dysfunction, physical abuse,
child abuse and neglect, or substance abuse. Unless these problems
are addressed, patients may have serious barriers that prevent them
from adhering to the prescribed regimen and keeping clinic appointments.
DOT is strongly recommended for potentially infectious patients
with significant adherence problems; in some areas, DOT is the standard
of care.

When patients have serious problems, the discharge team has an
opportunity to help them by providing appropriate referrals for
support and assistance. By helping patients with these other difficulties,
providers and public health workers are also helping patients successfully
complete TB therapy. Table 8.6 presents some examples of the service
providers the public health worker may want to contact for eligible
patients. Relationships with such providers can often be improved
by means of formal referral agreements and educational sessions
for staff about TB, including information on services the TB program
has to offer.

In some cases, the patient and his or her family may already
be receiving visits from social workers or public health nurses
for other conditions or problems; if this is the case, the discharge
team should get their input whenever possible. By helping to coordinate
care provided to a single patient, the public health worker can
often improve patient adherence and maximize the use of public health
resources. However, confidentiality is an important issue in working
with other agencies, and must not be compromised.

An appointment for DOT or for continued monitoring should be
made at a location that is convenient (and preferably, familiar)
to the patient. Whenever possible, the provider for the patient's
follow-up care should come to the hospital or institution to meet
the patient and explain the program that will be followed. The discharge
planner or case worker should notify the provider of the date of
discharge when it becomes known and of any changes in the treatment
plan or adherence plan.

The public health worker is responsible for conveying relevant
information on discharged patients to the TB program. This information
is very important for co-workers assigned to the case who will provide
follow-up care in the community.

Patients No Longer in the Facility

The public health worker may need to review the medical record
of a patient who has been discharged, has left the facility against
medical advice, or has died. In addition, it is sometimes important
to review the medical record from a patient's prior hospitalization
or stay in an institution. When a patient is no longer in the facility,
the patient's medical record is sent to the medical records department.
To access these records, the public health worker will usually complete
a medical record request form, providing the patient's name and
either a medical record number or the patient's date of birth. Each
facility has a specific procedure for requesting patient records;
the public health worker should become familiar with the procedure
used in the facility or facilities in which he or she works.

The medical records of patients who have been discharged often
will not have clearly labeled sections, even though they will still
be organized in the same manner as in-patient records. If the patient
has been discharged, a discharge summary may be
included in the medical record; this is a document written by the
patient's physician that contains a brief summary of all important
information from the entire hospitalization or stay in the institution.
The discharge summary contains the patient's discharge diagnosis
and often includes a plan for follow-up care. Although it is usually
a good place to start, the discharge summary should not be used
in place of a thorough record review.

Many patients are discharged before final culture and susceptibility
results are known; the public health worker may need to find the
patient's laboratory results and forward them to the current provider.
If a patient is discharged while still infectious (for example,
with positive AFB sputum smears), it is especially important that
the patient, his or her providers, and household members know this
and be able to act accordingly. Household members who have already
been exposed do not usually need to take special precautions, but
unexposed persons -- especially HIV-infected persons and children
-- should not be in contact with a patient who is still infectious.

Other information included in the medical record can help to

Locate a patient who has been lost to follow-up care

Identify a patient's next of kin

Locate information about contacts

Finally, the medical record may contain information about the
patient's next scheduled clinic appointment or provider in the community.

If a patient has died while in the facility, there will usually
be a death report and a pathology report in the medical record.
These reports should be reviewed along with the rest of the medical
record for information relevant to the contact investigation.

If the patient is being seen in an out-patient clinic
(a clinic that cares for non-hospitalized patients with a particular
type of problem; for example, chest, infectious disease, AIDS, pediatric)
associated with a hospital, the medical record may be found in the
medical records department or in the clinic files, if an appointment
date is near. If the medical record is in the out-patient clinic,
the public health worker must request it from the clinic supervisor
or a nurse, following the clinic's procedure for record requests.

HIV-infected patients will often be referred to an infectious
disease clinic for follow-up care or prophylaxis against opportunistic
infections after their discharge. If this happens, a case manager
is usually assigned to the patient. This person can often be helpful
in arranging follow-up care for TB disease and providing social
services, such as housing, that may be available through AIDS- or
HIV-related programs.

Inter-jurisdictional Referrals

Some patients who are in a hospital or another institution may
actually reside in a different health jurisdiction other than the
one in which the hospital or institution is located. Likewise, some
patients may move to another jurisdiction upon discharge from the
hospital or institution or at some other point during their treatment.
For example, a TB patient who is paroled or released from a correctional
facility may actually reside in a health jurisdiction other than
the one where the correctional facility is located. Similarly, seasonal
migrant farm workers may move between health jurisdictions often.

A patient may move to a health jurisdiction within the same state
or to another state. The public health worker needs to be familiar
with the guidelines and case referral processes in their health
jurisdiction in order to transfer information on TB patients who
move, as well as facilitate follow-up to ensure TB patients' continuity
of care. The end goal is completion of therapy for all TB patients.

When a patient leaves a health jurisdiction before completing
TB therapy, patient information should be sent to the patient's
destination health jurisdiction. The following procedures should
be followed:

Patients who are on antituberculosis treatment or treatment
for LTBI should be given records they can take with them to
indicate their current treatment and diagnostic status. Special
care should be taken to instruct such persons on how to take
their medications and how and where to get additional medication
and medical care at the destination sites.

All relevant medical information should be forwarded to
the destination jurisdiction. Some jurisdictions use a standard
form when referring patients between health jurisdictions. See
Figure 8.13 as an example of a referral form.

The state health department TB control officer should be
contacted and apprised of the need for follow-up and the next
possible destination of the patient.

Although sharing necessary information between health departments
is encouraged to ensure continuity of care, as well as protect
the public, measures should be taken to ensure confidentiality.

All information received on the TB patient, including TB
laboratory reports, after the TB patient departs for another
area should be immediately telephoned, faxed, or expeditiously
mailed to the receiving jurisdiction following procedures to
maintain patient confidentiality.

Out-of-state communications regarding TB care should be
routed through state health departments to ensure that the information
is transmitted and that necessary follow-up is initiated.

The referring jurisdiction should follow up and maintain
communication as needed until the patient is located in the
destination jurisdiction.

Receiving jurisdictions also have responsibilities to ensure
the continuity of care for TB patients, as well as the accountability
of the cases. Public health workers in receiving jurisdictions should
be prepared to receive the TB patient from the referring jurisdiction
and resume patient care.

If a forwarding address is provided by the referring jurisdiction,
the receiving jurisdiction should try to verify and visit the forwarding
address. The receiving jurisdiction should make every effort to
locate referred TB patients. The receiving jurisdiction should maintain
communication with the referring jurisdiction to ensure continuity
of care. If the patient cannot be located, and reasonable attempts
to locate the patient have been made, the receiving jurisdiction
should notify the referring jurisdiction of their inability to locate
the patient. The receiving and referring jurisdictions should work
with the state TB controllers in their area to inform them of the
situation and discuss other options for locating the patient.

Case Study 8.7You are the public health worker assigned to
the Buena Vista residential home for the elderly. There
are currently two TB patients in the facility who are
taking TB medications. They have been reported to the
TB program and will remain in the facility for the duration
of their TB treatment.

What are your concerns for ensuring the quality
of their case management?

While reviewing the patients' medical records, you find
that drug susceptibility testing has not been done on
either patient's isolate. Both patients are currently
on a standard, three-drug regimen that is appropriate
for your local area. However, you are somewhat disturbed
to find out that one patient, Mr. Sichler, was homeless
for a time and wandered from shelter to shelter in a
nearby city (with high drug resistance rates) before
coming to Buena Vista.

Case Study 8.8You have just been assigned to work in the
state prison, which houses several hundred prisoners
and usually has three to six TB cases per year. Currently,
two prisoners are taking TB medication and seven are
on regimens for the treatment for LTBI. Before you were
assigned to the prison, the standard procedure when
prisoners with TB disease were released was to notify
the health department. The health department would make
an appointment for the patient and, if the patient did
not come, send a reminder card to the patient's address
prior to incarceration (supplied by the prison administration).
The treatment completion rate for these cases has been
very low.

One of the prisoners with TB disease is near the
end of his sentence and has a hearing coming up in a
few days.

What can you do to plan for his release?

What information will you need from this patient
during your initial interview that will help discharge
planning?

Case Study 8.9You are a health care worker at the Gryson
County Health Department. You have been working closely
with Juan Garcia, a 35-year-old Hispanic agricultural
worker. Mr. Garcia was diagnosed with TB about 2 months
ago. You have been giving DOT to Mr. Garcia at a local
farm where he picks oranges. Orange season is coming
to an end and you realize that Mr. Garcia will soon
be heading North to look for more work. You have spoken
to him about where he will be going next. He tells you
that he is going to a farm in the next state. He is
not exactly sure where it is, but he thinks he remembers
the farm is located near a town called Jasper.

What steps will you take before Mr. Garcia leaves
to ensure the continuity of care?